Impella Mechanical Circulatory Support for Takotsubo Syndrome With Shock: A Retrospective Multicenter Analysis.

OBJECTIVES: To analyze the characteristics and outcome of Impella mechanical circulatory support (MCS) for Takotsubo syndrome (TS) with cardiogenic shock. BACKGROUND: TS is an acute heart failure syndrome characterized by transient severe reduction of left ventricular (LV) systolic function, with cardiogenic shock occurring in around 10% of patients. Since inotropes should be avoided due to their role in TS pathogenesis and aggravation of LV outflow tract obstruction, the use of MCS as treatment is a viable treatment option, however, studies are lacking. METHODS: The catheter-based ventricular assist device (cVAD) registry and local MCS databases were screened for TS patients with cardiogenic shock (TS-CS) supported with an Impella percutaneous ventricular assist device (pVAD). Patient and treatment characteristics and in-hospital outcomes were retrospectively analyzed. RESULTS: At 10 US and European centers, 16 TS-CS patients supported with an Impella pVAD were identified between December 2013 and May 2018 (mean age, 61.8 ± 15.5 years; 87.5% women). LV ejection fraction (LVEF) at presentation was severely reduced (mean, 19.4 ± 8.3%). Prior to MCS, 13 patients (81.3%) were mechanically ventilated, 4 patients (25.0%) had been resuscitated, and mean serum lactate was 4.7 ± 3.5 mmol/L. Mean duration of Impella support was 1.9 ± 1.0 days (range, 1-4 days). Thirteen patients (81.3%) survived to discharge, and all survivors experienced cardiac recovery with significant improvement of LVEF at discharge compared to baseline (20.4 ± 8.8 vs. 52.9 ± 12.0, P < 0.001). CONCLUSIONS: This is the first series of TS-CS patients supported with an Impella pVAD. Mortality was low, and LV systolic function recovered in all survivors. Prospective studies of Impella support in this special condition are warranted.

Predictive power of cardiovascular risk factors for detecting peripheral vascular disease.

OBJECTIVES: Peripheral vascular disease (PVD) is underdiagnosed in primary care due to the absence of established criteria to warrant diagnostic testing. Our goal was to establish a risk factor hierarchy to enable earlier diagnosis of PVD. METHODS: Data sets of 142 patients with abnormal ankle brachial indices (ABI) were randomly selected from our patient database to determine the prevalence of specific cardiovascular risk factors and demographic data. An ABI score < 0.90 is diagnostic of PVD. Patients were stratified into mild (0.75-0.89), moderate (0.50-0.74), and severe disease (< 0.50). RESULTS: Mean age was 69 +/- 9.9, ABI 0.65 +/- 0.16. Risk factor prevalence: diabetes, 42%; hypertension, 87%; tobacco use, 34%; hyperlipidemia, 53%; obesity, 24%; cardiovascular disease (CVD), 69%; stroke, 15%. Total risk factors per patient v = 3.2 +/- 1.3. Disease severity stratifications: mild, n = 46 (age v = 68.6 +/- 10.4, ABI v = 0.82 +/- 0.05); moderate, n = 72 (age v = 69.9 +/- 9.4, ABI v = 0.62 +/- 0.07); severe, n = 24 (age v = 67.5 +/- 10.9, ABI v = 0.40 +/- 0.06). Independent variable mean differences: hypertension-CVD (P = 0.0002); CVD-hyperlipidemia (P = 0.002); hyperlipidemia-diabetes (P = 0.0008); diabetes-tobacco use (P = 0.001); tobacco use-obesity (P = 0.0003); obesity-stroke (P = 0.05). Independent variable mean differences were significant across disease severity (P < 0.00001). CONCLUSIONS: Our study establishes the following hierarchy of cardiovascular risk factors as predictors of PVD: hypertension, cardiovascular disease, hyperlipidemia, diabetes, tobacco use, obesity, stroke.

Noninvasive coronary angiography: agreement of multi-slice spiral computed tomography and selective catheter angiography.

BACKGROUND: Technology advances in multislice detector computed tomography (MSCT) cardiac scanning, specifically in the application of intravenous injected contrast coronary angiography with EKG gating have led to the availability of this procedure in every day outpatient cardiac medicine. OBJECTIVE: The aim of this study is to test the head to head direct coronary angiography with MSCT coronary angiography in clinical situations where cardiac cath is traditionally utilized for management decisions. METHODS: We limited our analysis to vessels felt to be 1.5 mm or greater in diameter, recognizing diagnostic accuracy and medical importance of smaller vessels is low. All 50 patients (52% men, 48% women age range 34-78) were studied because of the clinical suspicion of obstructive coronary atherosclerosis. Blinded experts in direct and in MSCT independently read the studies and resolved disparities by a subsequent discussion. Standard protocols for direct and for MSCT angiography were used including use of IV and oral beta blockade to keep the heart rate at or below 60 beats per minute. RESULTS: 392 vessels were evaluated. MSCT provided images of sufficient technical quality to permit diagnosis in 98% (49/50) of cases. MSCT was 96% accurate in identifying patients as having either no disease, single vessel disease, or multiple vessel disease. For all vessels, MSCT identification of stenotic lesions of >50% were as follows: sensitivity 87%, specificity 97%, positive predictive value 80%, and negative predictive value 98%. Pearson correlation results between direct catheter and MSCT for absolute stenotic percentages were left main (0.92 p < 0.0001), left anterior descending (0.94 p < 0.0001), circumflex (0.94 p < 0.0001), first obtuse marginal (0.85 p < 0.0001), and right coronary artery (0.89 p < 0.0001). CONCLUSION: The accuracy of MSCT angiography compared favorably with that of direct cardiac cath in this cohort of patients. The high specificity of these findings suggest that one particular use of this technique will be to eliminate many unnecessary cardiac catheterization procedures by excluding obstructive, and therefore potentially PCI requiring, coronary artery disease. The medical cost savings of such an application may be very significant and bears further study.